Patient Identification Page 1 of 13 Version 1.0 October 2016 Standard Operating Procedure 1 (SOP 1) Patient Identification Why we have a procedure? The Trust takes the safety of service users seriously. The correct identification of service users is a priority in making sure that clinical and record keeping aspects of the service promote and ensure that mistakes are reduced and even eliminated. Guidance from the National Patient Safety Agency (NPSA) advocates the use of wristbands in acute inpatient settings (general/physical health) but acknowledges that they may not be appropriate in mental health settings. The Never Event List for 2012/13 from the Department of Health also acknowledges that mental Health Units are excluded from the use of wrist bands by local agreement. The Nursing and Midwifery Council state that “where there are difficulties in clarifying an individual’s identity, for example, in some areas of learning disabilities, patients with dementia or confused states, an up-to-date photograph should be attached to the prescription chart This SOP sets out the trusts decision to use photographs as the primary method of identification for people using inpatient services. The trust requires the use of wristbands as a secondary method. This does not replace the requirement to ask the Service User their name and date of birth. What overarching policy the procedure links to? Clinical Record Keeping Standards Policy Which services of the trust does this apply to? Where is it in operation? Group Inpatients Community Locations Mental Health Services all Learning Disabilities Services all Children and Young People Services all Who does the procedure apply to? Directors and other Senior Managers: must ensure that the organisation can fulfil the content and actions in the SOP, in terms of provision of training, conditions and resources. Ward/Team Manager and Service Managers: it is their responsibility to ensure that all staff, within their areas, are aware of this SOP. Managers need to be aware of how this procedure affects practice and training requirements for staff.
Transcript
Patient Identification Page 1 of 13 Version 1.0 October 2016
Standard Operating Procedure 1 (SOP 1)
Patient Identification
Why we have a procedure?
The Trust takes the safety of service users seriously. The correct identification of service users is a priority in making sure that clinical and record keeping aspects of the service promote and ensure that mistakes are reduced and even eliminated. Guidance from the National Patient Safety Agency (NPSA) advocates the use of wristbands in acute inpatient settings (general/physical health) but acknowledges that they may not be appropriate in mental health settings. The Never Event List for 2012/13 from the Department of Health also acknowledges that mental Health Units are excluded from the use of wrist bands by local agreement. The Nursing and Midwifery Council state that “where there are difficulties in clarifying an individual’s identity, for example, in some areas of learning disabilities, patients with dementia or confused states, an up-to-date photograph should be attached to the prescription chart This SOP sets out the trusts decision to use photographs as the primary method of identification for people using inpatient services. The trust requires the use of wristbands as a secondary method. This does not replace the requirement to ask the Service User their name and date of birth.
What overarching policy the procedure links to?
Clinical Record Keeping Standards Policy
Which services of the trust does this apply to? Where is it in operation?
Group Inpatients Community Locations
Mental Health Services all
Learning Disabilities Services all
Children and Young People Services all
Who does the procedure apply to?
Directors and other Senior Managers: must ensure that the organisation can fulfil the content and actions in the SOP, in terms of provision of training, conditions and resources. Ward/Team Manager and Service Managers: it is their responsibility to ensure that all staff, within their areas, are aware of this SOP. Managers need to be aware of how this procedure affects practice and training requirements for staff.
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Risk Manager: is responsible for the ensuring this document is reviewed and monitored in line with the Trust Policy on Procedural document. Nurse in Charge: 1) Checks service user details: Name (order & spelling of names), DOB, address,
GP, Check allergies/sensitivities 2) Record/correct details on personal profile word template 3) Method of identification discussed with service user, carer, and other
professionals 4) In the absence of Ward Clerk ask service user to sign consent form to either give
or refuse permission for taking a photo 5) In the absence of Ward Clerk to take service user photo and insert to personal
profile template via Microsoft Word 6) In the absence of Ward Clerk when the patient refuses to give consent make
wristband with the following details: 1. Full name (last name followed by first name), DOB, NHS number 2. Allergies or sensitivities to be recorded on a separate wristband for each allergy/sensitivity
Ward Clerk: 1) Record/correct details on personal profile word template 2) Ask service user to sign consent form to either give or refuse permission for taking
a photo 3) Take service user photo and insert to personal profile template via Microsoft Word 4) When the patient refuses to give consent make wristband with the following
details: 1. Full name (last name followed by first name), DOB, NHS number 2. Allergies or sensitivities to be recorded on a separate wristband for each allergy/sensitivity
When should the procedure be applied?
This procedure needs to be applied as soon as the service user enters any inpatient service across the whole Trust. This includes all inpatient services provided in Mental Health and Learning Disabilities.
How to carry out this procedure
Methods of Identification Two methods of identification were considered in the Trust wristbands and photographs. It should be emphasised that no single method is 100% reliable. All methods may also have ethical and legal issues regarding the privacy of personal information and the potential to create discrimination from personal factors such as background, Mental Health Act status, disability, stigma, cultural background and a person’s use of services. The decision was taken by the Trust that the primary method of identification would be by photographs with a secondary method of wristbands being available for specific areas. Establishing Method of Service User Identification Whilst the Trust advocates the use of photographs for many of the people using the inpatient services, flexibility is given that for some people and for some services an alternative approach (wristbands) may be more effective and acceptable.
If for cultural/religious or strong personal reason a person refuses to have their picture taken, a wristband should be used.
A method of identification is required for all people using inpatient services.
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Consent Guidance around consent is provided by the Trust in the Consent to Treatment policy. In order to gain and record consent the following steps must be taken: Full explanation of the reasons for the use of photographs will be given and patients will sign a consent form to either give or refuse permission of having a picture taken. Consent must be clearly recorded in the person’s health record in the same manner as other issues of consent. Capacity or Refusal If there is any doubt regarding a patient’s capacity regarding making a decision about having a photograph taken, an assessment should be done according to the Mental Capacity Act 2005. This should be documented within the case records. If a patient has capacity and consents to the photograph being done, the photograph should be taken. If a service user has capacity but does not consent to the photograph being done, the photograph cannot be taken. This decision should be documented in the clinical record. Staff should review this at a later date to determine if the patient later consents to the photograph being taken. The care/treatment plan must make reference to continued efforts to help the person engage. A balance needs to be struck between encouraging someone to understand and agree and not appearing intrusive or coercive. In these circumstances a wristband may be used. In the event of a service user with capacity refusing to have a photograph taken, a risk assessment should be completed and staff must ensure that extra care is taken to ensure that the patient’s identity is checked before any procedure takes place. This process must be detailed in the care/treatment plan. If a person lacks capacity but is compliant with interventions then the staff should proceed if in the patient best interest in discussion with carers / family and team members. If a person is unable or unreliable in being able to identify themselves, the need for a photograph is greater. As long as the ‘best interests’ of the person are being served and the photograph is stored safely and the persons privacy and dignity is respected then the photograph provides the most effective identification method. Resources Each inpatient area will have to make an assessment of the equipment and environment they need to take and print photographs. In acute areas this must be available on a 24 hour basis in order to ensure the safety of people newly admitted to hospital. Resources include:
Digital or other ‘quick print’ camera
Printing device
Paper of suitable quality to print onto
Well lit area with plain background to take pictures against
Access to ‘back up’ equipment in the event of failure/loss
Somewhere safe and locked to keep equipment in
Plans for maintenance and replacement of equipment
Area specific training for staff on the use of the supplied equipment
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The Photograph A head and shoulders photograph is sufficient for the use of identification (i.e. passport style). The picture used or available may show more of the person, but must have a clear view of their face and features. The following is simple advice about how to take a reasonable quality photograph.
Light background with no or minimal pattern
Background preferably not white or glossy as this produces glare
Good lighting on the face, not in shadow
Hair brushed away from the face but in usual style
If spectacles are worn they can be included as long as the eyes are clearly visible
Some lenses can produce glare, hiding features
If coloured contact lenses are worn this should be indicated on the back of the photo
Hijab’s, scarves or Buka’s can be worn and under no circumstances should women be asked to remove culturally acceptable headwear. Turbans and hats worn for cultural reason can be worn. It is not acceptable to make a person remove such items. It is, however acceptable to ask if they would feel comfortable pushing scarves back off the face a little. Individuals should feel more comfortable that a picture seen by many people and other professionals and people shows them appropriately attired. Where headwear is worn and only the eyes of the individual can be identified, then a wristband will be used
If the service user (reasonably) requests it Storage and Transport of Photograph Photographs must be kept securely attached to the person’s medicine card as the prescribing and administration of medicines is one clear area for the trust, where the identification of the right person and right medicine is of paramount importance. If a person does not take any medication then the photograph can be securely attached to the clinical record. It is the responsibility of the person in charge of each shift (usually the nurse) to ensure compliance and to rectify any problems. The Ward/Team Manager is responsible for developing and monitoring effective systems that assure the security of photographs taken in their area(s). It may be necessary for the medicine card to be transported out of the area (ward/unit/team) either to accompany the service user for treatment or transfer or on its own to Pharmacy etc. It is essential that the photograph remains:
Securely attached to the card
Returns with the card to the area
Hidden from public view (to protect privacy and confidentially during transit) Disposal of Photograph Any photograph taken remains the property of the Trust and will be maintained as part of the health record.
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Wristbands The NPSA guidance (for general hospitals) issued in July 2007 details standards for wristbands including colour, layout and allergy status. The NPSA also requires Trusts to be able to automatically generate wristbands from the patient information system by July 2009. The information on the wristband must include:
Full name (last name followed by first name), DOB, NHS number
Allergies or sensitivities to be recorded The following is a list of the potential risks involved in the use of wristbands
Data entered incorrectly or incompletely.
Erroneous data
Illegible writing
Information becoming blurred due to contact with water
Wristbands falling off It is essential that service users’ wristbands are checked regularly on completion and at least weekly, dependant on individual factors:
Risk of wristband causing injuries if caught/pulled
Wristbands being uncomfortable, causing allergies, irritation or pain especially in arthritis
Wristbands obstructing medical interventions i.e. intravenous drips, EEG
Wristbands falling off It is essential that care is taken when someone has a wristband on, that it is not too tight or too loose or causing irritation/discomfort or pain. If needed a wristband can be located on the ankles if there is a risk of obstructing medical treatment or if the service user prefers it. Staff must:
Be aware of reasons why patients may not consent to wear a wristband, due to factors such as not wanting to receive in-patient care, disorientation or impaired cognition
Acknowledge the presence of the wristband as being stigmatising (visible sign someone is ‘ill’)
Be aware of people swapping wrist bands (deliberately or inadvertently)
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Flow chart for establishing method of service user identification
1. Service User enters inpatient service
2. Check details: Name (order & spelling of names), DOB,
address, GP, Check allergies/sensitivities
3. Record/correct details on personal profile template
(Microsoft Word)
4. Method of identification discussed with service user,
carer, and other professionals
Patient gives consent for photo?
Primary method: photo taken & inserted to personal profile
template via Microsoft Word
Secondary method: make wristband with the following
details: 1. Full name (last name
followed by first name), DOB, NHS number
2. Allergies or sensitivities to be recorded on a separate wristband for each allergy/
sensitivity
Start
End
Yes
No
5. Service user signs consent form to either give or refuse
consent for photo.
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Where do I go for further advice or information?
Risk Manager
Training Staff may receive training in relation to this procedure, where it is identified in their appraisal as part of the specific development needs for their role and responsibilities. Please refer to the Trust’s Mandatory & Risk Management Training Needs Analysis for further details on training requirements, target audiences and update frequencies Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness.
Equality Impact Assessment Please refer to overarching policy
Data Protection Act and Freedom of Information Act Please refer to overarching policy
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Appendix 1 – Mental Health Consent to use Photographs Form
Date: _________________________
Consent to Use Photographs for Identification Purposes. Photographs will be used for Medicine Cards and other identification purposes which are compatible with the safe provision of care and the protection and wellbeing of the service user. To comply with the above, please confirm by signing this form that you either give or refuse permission for your photo to be used for identification purposes.
I confirm that I give/refuse (delete as appropriate) permission for my photo to be used for identification purposes. Signature _______________________________ Date ________________________ Print Name ____________________________
If Patient refuses consent reason for refusal:
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Appendix 2 – Learning Disabilities Consent to use Photographs Form
1 We would like to take a
2 Photograph of you
3
Name:
To make a
But we need you to say yes
or no to have your picture in
the
The will be kept at The Larches
The photographs will not be used for anything
else.
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Appendix 3 – Patient Profile Template
Salter Ward - Old Age Psychiatry – Personal Profile
Add Patient Label
Telephone Number:
Mobile Number :
MHA Status :
Height:
Weight:
Hair Colour:
Eye Colour:
Religion:
Ethnicity: I Dr ……………. Can confirm that this is a true likeness of: ……………………………..
Any Distinguishing Features:
Medical Conditions:
Any Other Information:
Add Patient Photograph
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Appendix 4
Guidance for taking Patient Photographs as Primary Method of Identification
Taking Photographs
Set the camera resolution to 2 megapixels as this is sufficient for the size of photograph required. Please refer to camera manual for further instructions
Remove the memory card so that the photograph saves to the internal camera memory and not memory card
Connecting the camera to PC via USB cable
Do not upload the photograph directly to the PC hard drive
When the camera is connected to the PC, you will be able to select the photograph directly from the memory card or camera memory, which will appear as a drive in the Windows file explorer drive list
Inserting Photograph to patient profile template
Open the template document and insert photo directly from the camera memory
The minimum size of photograph must be height of 45 millimetres and width of 35 millimetres. The photograph size must be within the box area of Add Patient Photograph
Complete patient profile template in Word
Complete all fields in patient profile template using Microsoft Word Saving patient profile template
Save the document with relevant and accurate details pertaining to each individual, with a unique identifying filename on a shared resource drive, not on the PC hard drive
Printing patient profile template
The patient profile template must be printed in colour via locked print so that the user printing the template is near the printer when the template is being printed
Deleting Photographs
As soon the image is inserted to the Patient profile template and it has been saved, the image on the camera must be deleted
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Appendix 5
User Guide for Inserting Patient Photograph to Template on Microsoft Word
1. Open Personal Profile Template using Microsoft Word.
2. Select Add patient photograph text and delete (leave mouse cursor in the area
to insert photograph).
3. Select Insert tab and click option.
4. Locate the correct photograph, select it and click button.
5. If you need to crop the photograph, then double click the mouse on the
photograph and select the button on the top right side of the window. When
you have finished cropping the photograph click the highlighted button to
apply changes to the photograph.
6. To resize photograph click the left mouse button on any corner of the
photograph and drag to either expand or decrease size of photograph. The size
of the photograph needs to remain within the photograph box area.
Insert patient photograph in this area directly from camera connected to PC via USB.
Update title with appropriate Ward details.
Patient Identification Page 13 of 13 Version 1.0 October 2016
Standard Operating Procedure Details
Review and Amendment History
Version Date Description of Change
1.0 Oct 2016
New SOP for BCPFT
Unique Identifier for this SOP is BCPFT-CLIN-SOP-13-1
State if SOP is New or Revised New
Policy Category Information Governance
Executive Director whose portfolio this SOP comes under
Medical Director
Policy Lead/Author Job titles only
ICT Business Analyst
Committee/Group Responsible for Approval of this SOP
Information Governance Steering Group
Month/year consultation process completed
Month/year SOP was approved October 2016
Next review due October 2019
Disclosure Status ‘B’ can be disclosed to patients and the public
